The Royal Australian College of General Practitioners
Recommendations from the Royal Australian College of General Practitioners (RACGP) on treating hypertension or hyperlipidaemia, prescribing benzodiazepines, self-monitoring of blood glucose, proton pump inhibitor therapy and screening for vascular disease. The Royal Australian College of General Practitioners (RACGP) is Australia’s largest professional general practice organisation and represents urban and rural general practitioners. We represent more than 30,000 members working in or towards a career in general practice. There are more than 125 million general practice consultations taking place annually in Australia.
Don’t order colonoscopy as a screening test for bowel cancer in people at average or slightly above average risk. Use faecal occult blood screening instead.
This recommendation does not apply to people with a bowel symptom such as bleeding. Approximately 98% of Australians are at ‘average’ or ‘slightly above average’ risk (e.g. one relative with bowel cancer diagnosed at ≥ 55yo).
RACGP guidelines recommend two-yearly faecal occult blood testing (FOBT) from 50-75 years of age. The best available data to 2011 suggests 13% of this group were instead over-screened using colonoscopy.
National Bowel Cancer Screening Program (NBCSP) data shows that, per 10,000 people in this group followed up for an average 18 months, 6 will die from bowel cancer if unscreened. If screened with colonoscopy, 2.3 will die (1.5 from bowel cancer plus 0.8 from colonoscopy complications), compared to just 1.9 deaths for FOBT. A colonoscopy also risks bowel perforation (7 per 10,000), involves bowel preparation, and costs around $3000. NBCSP monitoring shows that a negative FOBT is 99.9% specific in ruling out bowel cancer.
Recommendation released March 2016
- RACGP, Red Book Taskforce. Guidelines for preventive activities in general practice. Royal Australian College of General Practitioners: Melbourne (2012). Available from: http://www.racgp.org.au/your-practice/guidelines/redbook/early-detection-of-cancers/colorectal-cancer-%28crc%29/
- Ouakrim DA et al. Screening practices of Australian men and women categorized as ‘‘at or slightly above average risk’’ of colorectal cancer. Cancer Causes Control 2012;23:1853–1864. (The 13% figure taken from the latest, unpublished data, received via correspondence from the primary author, Oct 2015).
- Emery J. NHMRC Centre for Research Excellence for Optimising Colorectal Cancer Screening at the University of Melbourne. AIHW data, National Bowel Cancer Screening Program.
- Viiala CH, et al. Complication rates of colonoscopy in an Australian teaching hospital environment. Internal Medicine Journal 2003;33:355-9.
- Australian Institute of Health and Welfare. Analysis of bowel cancer outcomes for the National Bowel Cancer Screening Program. 2014 Canberra: AIHW cat. no. CAN 87. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129549722
Recommendations 1 - 5 (April 2015)
All RACGP members were invited, and five GPs selected, to join the Choosing Wisely panel. They raised 28 issues, researched these and voted on a shortlist of 10. The voting for this shortlist was based on the amount of supporting evidence available, the degree of importance for patients, and the frequency of the test or treatment being used by Australian GPs. Opinion from the entire College membership was then sought via online survey, to choose five of the shortlisted 10. Additional free-text comment was encouraged, with good response rates. This national vote determined the final five topics.
Following an NPS Representatives meeting, two on that list were found to duplicate other Colleges' choices, and it was felt the RACGP could endorse these rather than replicate them. Therefore the next two highest voted options were selected instead.
Recommendations 6-10 (March 2016)
The RACGP Working Group established for Wave 1 of Choosing Wisely identified 32 candidate topics for Wave 2, then shortlisted fifteen, spread across four categories – screening, imaging, pathology and treatment. The shortlisting criteria were: quality of supporting evidence; importance for patients; and number of Australian GPs using the test or treatment. A dedicated workshop was held at the RACGP Annual Scientific Meeting, ‘GP15’, and the entire RACGP membership was asked to vote for their ‘top five’ via online survey. Additional free-text comment was encouraged, with good response rates. The top five topics from this national vote were written up by the Working Group and reviewed by the RACGP Expert Committee – Quality Care.
- 1 Don't use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing.
- 2 Don’t commence therapy for hypertension or hyperlipidaemia without first assessing the absolute risk of a cardiovascular event.
- 3 Don’t advocate routine self-monitoring of blood glucose for people with type 2 diabetes who are on oral medication only.
- 4 Don't screen asymptomatic, low-risk patients (<10% absolute 5-year CV risk) using ECG, stress test, coronary artery calcium score, or carotid artery ultrasound.
- 5 Avoid prescribing benzodiazepines to patients with a history of substance misuse (including alcohol) or multiple psychoactive drug use.
- 6 Don’t order colonoscopy as a screening test for bowel cancer in people at average or slightly above average risk. Use faecal occult blood screening instead.
- 7 Don’t order chest x-rays in patients with uncomplicated acute bronchitis.
- 8 Don’t routinely do a pelvic examination with a Pap smear.
- 9 Don’t treat otitis media (middle ear infection) with antibiotics, in non-Indigenous children aged 2-12 years, where reassessment is a reasonable option.
- 10 Don’t test thyroid function as population screening for asymptomatic patients.